Hearts on their sleeves: what drives us to get – and often regret – tattoos?

It’s thin, the barrier that separates us from the world – when I see skin blister or crack I’m often startled by just how insubstantial it is. The subtlest of scratches may leave a scar; the most trivial of abrasions may drive dirt under the skin and leave a permanent stain. The first tattoos must have been like this, unintentional, ash or mud forced into the body through falls or flint wounds.

A few years ago I had a clinical attachment to a medical research unit in East Africa. One of the local doctors, Faith, took care of me. She had trained in Nairobi and was efficient and imperturbable. As she led me on her rounds she spoke of her grief at the corruption that robbed funds from the hospital. One of the hundreds of bedside stops we made together was to a malnourished boy, about eight years old, who lay face down on a dirty bed. He had cerebral palsy, had fallen in a fire, and before coming to the hospital had been nursed at home. Mottled burn scars made a chiaroscuro of his back. Embedded in the burn scars were flecks of charcoal that would now be almost impossible to remove – if he survived, he’d carry their marks for the rest of his life.

For accommodation I rented a bungalow in an empty holiday complex near the hospital. One day the manager’s ex-husband arrived, sacked the staff , switched off the water supply and locked the main gate. For a couple of days I had to wash my clothes and dishes in the pool, until I found a room in another house with some colleagues, further away from the hospital but next to the beach. It was a round house, surrounded by the bush, open to the air and with iron bars instead of walls, and it came with a resident population of giant millipedes, dive-bomber beetles and smug, fat geckos. Within the toilet rim lived a colony of tiny frogs, naturally selected to swim fast enough to avoid being flushed away.

At night I’d hear the sounds of partying carry through the trees from the house next door. The neighbours at that time were Samburu warriors from the highlands of Kenya. They had recently been the subject of a documentary, and had come down to the coast to celebrate with the film’s director. At an evening party I was taken aside by one of the men: he didn’t like it down by the Indian Ocean, he told me – too hot, too many people and the locals ate too much fish. No self-respecting Samburu would
eat such food.

Around his thighs he had a pattern of circular scars: raised, shiny blebs, as if divots of flesh had been prised out with thorns, then left to heal. I asked how he had got them. “It’s done with burning sticks,” he said; “we do it when we become moran, warriors.” He ran his fingers over the scars, remembering. “For days afterwards it was very hard to walk.” The whorled patterns of the markings were like fingerprints writ large. Others on his trunk were arranged in neat cubic geometries, like I Ching ideograms cast over the body. The young men in his tribe were all marked this way, he said, before they were expected to go out to fight against neighbouring tribes, such as the Turkana.

“Did you ever fight the Turkana?” I asked.

He shook his head. “They are near to Somalia. They have AK47s.”

He’d visited Edinburgh once for the film festival. “Very cold”, he remembered. I imagined this African warrior, skin like polished anthracite, scars hidden beneath blue jeans, bracing himself against the icy brine of the North Sea wind.

Geometries of the flesh: patterned scarring, known as scarification, on a woman in South Sudan​. Credit:Stefanie Glinski/ AFP/ Getty

In my clinic in Edinburgh I often see another kind of scarification – the “deliberate self-harm” of those who cut themselves in moments of intense anguish. I asked one of my patients, Calvin, how he’d fallen into the habit: “It started in secret,” he said,”‘something I did in my own bedroom. I’d take a razor, or unscrew the blade from a pencil sharpener, and just nick the skin ever so slightly. Just enough to draw blood. I’d catch the blood in tissues, then smuggle the dirty tissues out to a bin far from the house. It made me feel better, for a while. But then worse, you know, afterwards.”

“Where did you cut yourself?” I asked.

“At first just here” – he pointed to his hip – “so that if I was wearing shorts no one would be able to see the scars.”

Calvin pulled down the waistband of his trousers and half-stood to show me: a marbled lattice of white lines overlaid his hip.

“Then it wasn’t enough – I switched to the other hip, and then my forearms. At the beginning I thought I could just wear long sleeves, and then I didn’t care any more. Something switched in me – I wanted others to see the scars. I wanted my mum, my dad, my teachers, everyone around me to see how unhappy I was.”

We were both silent for a few seconds. “What do you think about them now?” I asked.

“For a long time I was happy to have them. That phase in my life is past, but it’s a big part of me. It’s part of who I am. Those scars are a relic of my past self – I don’t want to get that low again. Until recently, each time I glanced down and saw the scars, I remembered how much stronger I am these days.”

I’d been seeing Calvin for a year or so, weaning down his antidepressants slowly, checking in on the counselling and the confidence-building courses he’d signed up for. “And now?”

“And now I’m ready to move on. I’m going to leave that part of my life behind forever. I’ve decided to get tattoos, I’m going to cover them all.”

For some, the act of being tattooed is related to the same impulse to cut, but for Calvin each tattoo was a step away from the person he’d been. Over the next few visits I watched his tattoos evolve. First a Chinese dragon coiling over his left hip, flicking its tail up over the crest of his pelvis and towards his spine; “It means vigour for me,” he said, “a reminder that I’ve got hidden strength.” I looked closely – the scarring was barely noticeable. Then, a few months later, I saw him again: his right hip was overlain with a lion rampant. “It’s bold and proud, like I want to be.” Over the following year, on his right forearm, there evolved a scene of winged angels mounted on clouds, the trumpet blasts of heaven radiating around them like discharges of electricity. In the pale gaps of skin there bloomed a garden of flowers. On his left arm grew a hellish scene: ghouls, skulls and trident-bearing demons, with fanged snake heads crammed in the spaces.

“I’m caught in the middle,” he said, pointing at his torso; “with hell on my left side” – at this he lifted his left forearm with its demons – “and heaven on my right” – he lifted the angels and trumpet blasts.

“You’re carrying both around with you,” I said.

“Don’t we all? You must see that in your job.”

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In the Sherlock Holmes stories, Arthur Conan Doyle implies that the discerning detective can learn much about a person from their tattoos. “I have made a small study of tattoo marks,” Conan Doyle has Holmes say, “and have even contributed to the literature of the subject.” The tattoo is valued as a living testimonial to the life history of its bearer – as valuable to the physician as to the detective.

Often, when I roll up a sleeve to take blood pressure, or pull up someone’s shirt to listen to their lungs, I see tattoos that ordinarily go unseen. Some are about family ties: the names and birthdays of children, or fidelity to a partner. Some tell me about military tours of duty. Tattoos of bikers, soldiers, sailors and prisoners all bear witness to membership of a closed, tiered society. I remember opening a shirt to test a man’s belly for appendicitis, to see his torso inscribed in a flowing copperplate: “worrying is praying for the worst to happen”. His tattoo was a kind of self-uttered enchantment: he told me that since getting it, his lifelong anxiety had gone.

Tattoos can be helpful to the clinician in a direct, practical way: one patient of mine could point to exactly where among a writhing sleeve of snakes to plunge a needle to be sure of getting blood. Some are about forging a bond between the present and the future self – a permanent keepsake of how its bearer used to be: a flower at the ankle, a rosette at the base of the spine, a cartoon character on a shoulder. And I’ve seen some that are emblems of transcendence and celebration: a phoenix rising from the ashes of a mastectomy scar, a garden of flowers blooming over stretch marks.

Tattooing must be among the earliest of art forms – the body as canvas, as symbol, as commemoration, as welcome and as warning. They’re frameless works of art, transformations of the body surface – itself subject to ceaseless change. They break down the distinction between subject and object. Sometimes they’re dismissed as something you’d get on impulse, but for most people, getting a tattoo is painful – as the poet Michael Donaghy pointed out, you’d need a “whim of iron”. The word is Polynesian – it came into global usage with the voyages of Captain Cook, and refers to the “tat-tat-tat” repetition of the needle as it punctures the skin (the drum roll “tattoo” of a military band has the same origin).

It can be the puncturing of the skin that brings a tattoo to my medical attention – infections, blistering, sometimes inflammatory reactions to ink. Psychological reactions too – around half of tattoo recipients regret them. In the United States a quarter of all young and middle-aged people have a tattoo, and there are more than 100,000 tattoo-removal procedures each year.

Historically there have been hundreds of reasons for getting tattooed. Anthropologists have listed a few: camouflage for hunting; to mark and propitiate puberty and pregnancy; to counteract disease; improve fertility; to mollify malign spirits. Some of the motives identified among tribal societies are just as relevant among my own patients: to take on new characteristics; to honour ancestors or descendants; to enhance one’s respect among the community; to frighten enemies; to make the body a register of life events; to beautify oneself; to express an emotion; to demonstrate group allegiance. Some motives seem unique to contemporary culture: as permanent facial make-up, or even to make money exhibiting yourself. I’ve heard of someone who tattooed his blood group on to his arm, in case he ever needed a transfusion (with an arrow pointing at the broadest vein). And there are more baleful reasons: being branded by a fascist regime; as an act of deliberate self-harm; or to relieve boredom in a prison cell.

Of the latter two, the tattoos of prisoners tell a story of bravado, isolation and violence, or affirm allegiance and status. Some prison cultures, like those in Russia or South Africa, have elaborate tattoos that symbolise crimes committed – coffins to signify a murderer, a dagger at the throat for a mercenary, wrist manacles or numerals to signify the number of years incarcerated. For the prisoner, the body can be the only possession left – and the only weapon of rebellion. I’ve seen clumsy self-inked allegories of freedom restrained; of gardens and birds intertwined and tangled with thorns. I’ve seen scrawled skulls reminiscent of the memento mori skeletons that dance around the borders of old gravestones. Tattoos are a way of bringing disorder and creativity to a body living within the drudgery and order of the prison. The body in chains comes to tell a story of its own liberation.

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The first I knew of Mark Blakewell was a sheet of paper sent in to the medical practice from the city jail: “The above-named patient is being released from prison tomorrow,” it said, “I’d be grateful if you would take over the methadone prescription as detailed below.” Methadone is an opiate substitute, prescribed to dull the cravings of heroin addicts. I looked up the notes from before his conviction: a catalogue of emergency department attendances for fight injuries, and a couple of psychiatric referrals to which he didn’t turn up. Then a sudden silence, about ten years previously. The following day he showed up in my office.

He was thin and pale, in his early forties, with crew-cut blonde hair, and tight, bloodless lips. There were lines notched into his eyebrows. He wore a green tracksuit with white stripes, and down one cheek he had twinned scars. He blinked too often, and his eyes fidgeted around the room. But the most striking thing about him was his tattoos – all amateur works, executed in thick blue ink. A spider’s web was drawn up one side of his neck, and a dagger, pointing towards his heart, tattooed down the other. There were some tears tattooed on to one cheek; a loop of barbed wire circled his throat. Through his thin hair I could make out more designs on his scalp – a swastika, a skull and a Scottish flag. I glanced down at his hands: he had “LOVE” tattooed across his right knuckles, and “HATE” across his left. On his thumb knuckles he had clusters of blue dots, and a swallow fluttered at the web space between his right thumb and index finger.

He sat down next to my desk, and glowered. He had skin creases like target circles around his eyes. “I’ve come for my methadone,” he said.

“Sure. What dose are you on?”

He sighed theatrically: “If you don’t know that already, you don’t know what you’re doing.”

“I’m just checking I’ve got the right details.”

“Eighty,” he said. “And I need my Valium too.”

“Eighty, fine. But I can’t give you Valium – no one comes out of prison on Valium.”

“If you think we can’t get it there you really don’t know what you’re doing. If you don’t give me any, I’ll have to buy it on the street. Then it’ll be your fault when the police come after me.”

“If you’re so nervous you have to buy street Valium, then maybe we should talk about how to ease your anxiety.”

He grunted, grabbed the prescription from my hands, and went to stand up. Then the mask of fury on his face softened, he exhaled slowly and sat down again.

“Sorry,” he said, and looked down at his shoes. He looked as if he was trying to find the words to say more.

“I’ll be civil to you, if you’ll be civil to me,” I said.

He sat back in his chair and took a deep breath. “OK, let’s start again.”

Each of my patients on a methadone prescription is seen monthly, and over the months, as I came to know Mark better, he grew his blonde hair long. It curled around his ears and cast the spider’s web and dagger into shadow. The tattooed tears on his cheek were still prominent, and through his open-necked shirt I’d glimpse the barbed wire girdling his throat. On that first day out of prison I’d watched him manage to get his temper under control; slowly, I watched him do the same with his drug use.

One day he came in with a bandaged hand. He was wearing a polo-necked shirt, and was down from 80 to 40 millilitres of methadone a day. We agreed to drop it to 35. He told me he’d found a job in a mechanic’s shop. “And what happened to your hand?” I asked.

“Tattoos,” he said. “I burned one with battery acid.”

I unwrapped the bandage: weals of reddened skin were healing over his knuckles, but blue ink was already showing through the scabs.

“They used to try this in the old days,” I said. “They’d peel off tattooed skin, then graft new skin over the wound. It doesn’t work very well – they use lasers now.”

“And does it work?” he asked.

“Sometimes,” I said. “And your tattoos are the kind it’s best for. Not cheap, though.”

The lasers for tattoo removal are chosen according to the colour of pigment to be broken down – red and orange pigments need a green laser, a red laser is used for blues and blacks. It’s painful too – more painful than getting the tattoo in the first place. The lasers usually lighten the skin, which can be a problem for anyone with a dark skin tone.

I went on meeting Mark every month, bringing his methadone down by increments – and as his addiction eased, I watched his tattoos dissolve. By the time he was at 30 millilitres a day, the tattooed tears on his cheek were just faint smudges, barely noticeable. He was living frugally, spending all of his income on the laser clinic. By 25 millilitres the dagger and webs at his throat were fading, and I could see he had started on the circle of barbed wire at his throat. By 10 millilitres a day there were just blemishes to see on his face and neck, though he still had to keep his hair long enough to prevent the scalp tattoos
showing through.

A year or so later I saw him in clinic again. He looked well – as he walked into my office his once grey, zipper-tight lips opened wide in a smile. He wanted me to prescribe something to help him stop smoking. I noticed the swallow still fluttered at the web space between the thumb and index finger of his right hand.

“What about that one?” I asked him, pointing down at the free-flying bird.

“That one I’m keeping,” he said.

“Shapeshifters: On Medicine and Human Change” by Gavin Francis is published by Profile/Wellcome